Page 14 - DECISION-MAKING IN SEVERE TRAUMATIC BRAIN INJURY PATIENT OUTCOME, HOSPITAL COSTS, AND RESEARCH PRACTICE

Chapter 1
for treatment. It could only be anticipated by preventative measures. 18 More extensive primary injury is usually seen in more severely injured TBI patients, and is likely to be related to the development of secondary brain injury.
Secondary brain injury occurs from insults to the brain in the hours, days or months after the initial injury. 13,17 It is mainly triggered by hypoxia and hypovolaemia caused by systemic insults or increased intracranial pressure (ICP) as a result of intracranial hematomas, brain swelling, cerebral oedema or ischemia. 13 Other causes are impaired haemostasis, the consequences of neurotransmitter release, or a damaged blood-brain barrier with leakage of immune cells and a subsequent increased neuroinflammatory response with brain swelling. 13,17 Secondary injury is considered to be reversible and is suitable for treatment. 13,17
Treatment strategies
Immediate treatment in the pre-hospital or hospital setting could prevent or reverse secondary injury and associated brain dysfunction and might therefore be beneficial for patient outcome. 1,13 Trauma patients are usually treated by using the ATLS (Advanced Trauma Life Support) principle: ‘treat first what kills first’. 19 When necessary, this includes the prevention and/or normalisation of hypoxia and hypovolaemia by using intubation, oxygen supplementation, fluid resuscitation, or acute treatment of extracranial injuries, before focussing on the neurological status of the patient. 19 After neurological assessment, a CT scan is made to identify potential treatable or operable traumatic intracranial abnormalities, including diffuse axonal injury, diffuse swelling, subarachnoid haemorrhage, contusions, and epidural or subdural hematomas (Figure 1). Traumatic intracranial hematomas are rare in patients with mild TBI, but occur in 25-35% of patients with s-TBI and in 5-10% of patients with moderate TBI and could require immediate or delayed surgical intervention to prevent secondary injury. 13,20
Surgical intervention options include the placement of an ICP monitor or extraventricular drain, a craniotomy with evacuation of a haemorrhagic focus, or a decompressive craniectomy. 20 Surgical management is often combined with perioperative ICU treatment that also focusses on the prevention of secondary injury and the optimisation of conditions for brain recovery. 13,21 The necessary individualised and targeted approaches are nearly only possible at specialised ICUs. 21 When ICU admission is not required, patients will be admitted to a medium care or general ward. Provided care obviously depends on a patients’ clinical condition,
12